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'''Editor(s)-In-Chief:''' {{ATI}}, [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com]; '''Associate Editor(s)-In-Chief:''' {{CZ}} ; [[User:Kashish Goel|Kashish Goel, M.D.]]; '''Assistant Editor(s)-In-Chief:''' [[User:Justine Cadet|Justine Cadet]]
{| class="infobox" style="float:right;"
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| [[File:Siren.gif|30px|link=Deep vein thrombosis resident survival guide]]|| <br> || <br>
| [[Deep vein thrombosis resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
|}
'''Editor(s)-In-Chief:''' {{ATI}}, [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com]; {{AE}} {{CZ}} ; [[User:Kashish Goel|Kashish Goel, M.D.]]; [[User:Justine Cadet|Justine Cadet]]; {{Rim}}
{{Deep vein thrombosis}}
{{Deep vein thrombosis}}
==Overview==
==Overview==
A proper history and physical exam is very important for establishing an accurate diagnosis of deep vein thrombosis (DVT) or venous thromboembolism ([[VTE]]). DVT can be either asymptomatic or associated with tenderness and swelling of the calf or [[thigh]].  One of the first steps in the management of [[DVT]] is the determination of the [[Pretest probability of DVT#Wells score|Wells score for DVT]]. Out of the 10 clinical questions in the score, 9 can be ascertained solely on the basis of history and physical exam. This underscores the importance of these variables. A high index of suspicion is also necessary to diagnose [[DVT]].
A proper history and physical exam is very important for establishing an accurate diagnosis of deep vein thrombosis (DVT). DVT can be either asymptomatic or associated with tenderness and swelling of the calf or [[thigh]].  One of the first steps in the management of DVT is the determination of the [[Pretest probability of DVT#Wells score|Wells score for DVT]], whose criteria can be ascertained solely on the basis of history and physical exam. A high index of suspicion is also necessary to diagnose [[DVT]].  DVT can be complicated by [[pulmonary embolism]] (PE); therefore, it is important to inquire about the symptoms of [[PE]] among patients suspected to have DVT.


==History==
==History and Symptoms==
Only 10-20% of VTE is clinically recognized, as depicted by the figure below
As depicted in the image below, the majority of patients with venous thromboembolism (VTE), that is [[DVT]], [[PE]], or both, are asymptomatic.


[[File:Challenge of Assessing VTE.JPG|300x400px|The challenge in diagnosis of VTE]]
[[File:Challenge of Assessing VTE.JPG|300x400px|The challenge in diagnosis of VTE]]


As VTE involves both DVT and PE, the patient can present with complaints of either of the disease.
===Common Symptoms of DVT===
*With PE, depending upon the severity of the disease, the patient experience
The classical symptoms of DVT include:
**[[Dyspnea|Shortness of breath]]
* [[Pain and nociception|Pain]] in the affected area
**[[Syncope|Loss of Consciousness]](in case of massive PE.)
* [[Swelling]] of the affected area
*A smaller PE near the pleura can present with
* [[Erythema]] around the affected area
**[[Chest pain|Pleuritic chest pain]]
* [[Dilation]] of the surface veins and [[erythema]] of the overlying area
**[[Cough]]
**[[Hemoptysis|Blood in sputum]].
*While with DVT, patient can complain of
**swelling of lower extremity which can be warm and tender.


In patients having known [[Deep vein thrombosis risk factors|risk factors]], a careful history should be taken. It must include the following:
However, sometimes there may be no symptoms referable to the location of the DVT.
* History of any recent surgical procedure.
* Use of [[hormonal contraception]], containing [[estrogen]].
* Recent, long-term flying.
* History of a [[miscarriage]] (which can be a feature of thrombosis and several other disorders). 
* A family history can reveal a [[genetic disorder|hereditary]] factor in the development of DVT. A '''positive family history''' in one or more first-degree relatives under age 50 suggests the presence of a hereditary defect and/or an increased susceptibility for [[VTE]].<ref name="pmid19307525">{{cite journal| author=Bezemer ID, van der Meer FJ, Eikenboom JC, Rosendaal FR, Doggen CJ| title=The value of family history as a risk indicator for venous thrombosis. | journal=Arch Intern Med | year= 2009 | volume= 169 | issue= 6 | pages= 610-5 | pmid=19307525 | doi=10.1001/archinternmed.2008.589 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19307525  }} </ref>


<gallery>
Shown below is a picture depicting unilateral swelling and redness in a leg affected with DVT.
Image:Extremities dvt.jpg|Front View:Edematous Right Leg
Image:Extremities dvt2.jpg|Rear View:Left limb edema localized to calf.
Image:Extremities dvt3.jpg|Front View:Left limb edema localized to calf. 
</gallery>


==Symptoms==
[[image:Deep vein thrombosis Unilateral leg swelling and redness.jpg|left|thumb|250px|Unilateral swelling and redness in a leg affected with DVT By James Heilman, MD - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=9444797]]
===Common Symptoms===
 
The classical symptoms of DVT include:
<br style="clear:left" />
* [[Pain and nociception|Pain]] in the affected area.
* [[Swelling]] of the affected area.
* [[Erythema]] around the affected area.
* [[Dilation]] of the surface veins and [[erythema]] of the overlying area.


However, sometimes there may be no symptoms referable to the location of the DVT.
===Less Common Symptoms of DVT===
* In [[phlegmasia alba dolens]], the leg is pale and cold with a diminished arterial [[pulse]].  


There are several techniques done during a physical examination which can increase the detection of DVT. Some of these techniques are measuring the circumference of affected limb, measuring the circumference of the contra-lateral limb at a fixed point, and palpating the [[vein|venous]] tract, which is often tender. Physical examination is unreliable for excluding the diagnosis of deep vein thrombosis and [[Homans sign]] is not recommended for this.
* In [[phlegmasia cerulea dolens]], there is an acute and near-total venous occlusion of the entire extremity outflow, including the [[iliac vein|iliac]] and [[femoral vein]]s. The leg is usually painful, [[cyanosis|cyanosed]] and [[edema|edematous]].


===Less Common Symptoms===
===Symptoms of PE===
In [[phlegmasia alba dolens]], the leg is pale and cold with a diminished arterial pulse.  
Since VTE involves both DVT and [[PE]], the patient can present with complaints of either of the diseases. Therefore it is important to inquire about the symptoms of both diseases.  Symptoms of PE include:
* [[Dyspnea]] (78–81%)<ref name="pmid24182642">{{cite journal| author=Cohen AT, Dobromirski M, Gurwith MM| title=Managing pulmonary embolism from presentation to extended treatment. | journal=Thromb Res | year= 2014 | volume= 133 | issue= 2 | pages= 139-48 | pmid=24182642 | doi=10.1016/j.thromres.2013.09.040 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24182642  }} </ref> <br>
* [[Pleuritic chest pain]] (39–56%)<ref name="pmid24182642">{{cite journal| author=Cohen AT, Dobromirski M, Gurwith MM| title=Managing pulmonary embolism from presentation to extended treatment. | journal=Thromb Res | year= 2014 | volume= 133 | issue= 2 | pages= 139-48 | pmid=24182642 | doi=10.1016/j.thromres.2013.09.040 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24182642  }} </ref>  <br>
* [[Fainting]] (22–26%)<ref name="pmid24182642">{{cite journal| author=Cohen AT, Dobromirski M, Gurwith MM| title=Managing pulmonary embolism from presentation to extended treatment. | journal=Thromb Res | year= 2014 | volume= 133 | issue= 2 | pages= 139-48 | pmid=24182642 | doi=10.1016/j.thromres.2013.09.040 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24182642  }} </ref> <br>
* [[Cough]] (20%)<ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref><br>
* [[Substernal chest pain]] (12%)<ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref><br>
* [[Hemoptysis]] (11%)<ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref><br>
* [[Wheezing]] <br>
* [[Cyanosis]] (11%)<ref name="pmid24182642">{{cite journal| author=Cohen AT, Dobromirski M, Gurwith MM| title=Managing pulmonary embolism from presentation to extended treatment. | journal=Thromb Res | year= 2014 | volume= 133 | issue= 2 | pages= 139-48 | pmid=24182642 | doi=10.1016/j.thromres.2013.09.040 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24182642  }} </ref> <br>
* [[Fever]] (7%)<ref name="pmid24182642">{{cite journal| author=Cohen AT, Dobromirski M, Gurwith MM| title=Managing pulmonary embolism from presentation to extended treatment. | journal=Thromb Res | year= 2014 | volume= 133 | issue= 2 | pages= 139-48 | pmid=24182642 | doi=10.1016/j.thromres.2013.09.040 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24182642  }} </ref> <br>
* Symptoms suggestive of [[shock]] (in case of massive PE)
** [[Altered mental status]]
** [[Cold extremities]]
** [[Cyanosis]]
** [[Oliguria]]


In [[phlegmasia cerulea dolens]], there is an acute and near-total venous occlusion of the entire extremity outflow, including the iliac and femoral veins. The leg is usually painful, cyanosed and edematous.
===Complete History===
If VTE is suspected or diagnosed, a complete history should be elicited, including the following:
* '''Risk factors'''<ref name="pmid12814980">{{cite journal| author=Anderson FA, Spencer FA| title=Risk factors for venous thromboembolism. | journal=Circulation | year= 2003 | volume= 107 | issue= 23 Suppl 1 | pages= I9-16 | pmid=12814980 | doi=10.1161/01.CIR.0000078469.07362.E6 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12814980  }} </ref><ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref>
** [[Chemotherapy]]<br>
** [[Chronic heart failure]]<br>
** [[Respiratory failure]]<br>
** [[Hormone replacement therapy]]<br>
** [[Cancer]]<br>
** [[Oral contraceptive pills]] <br>
** [[Stroke]] <br>
** [[Pregnancy]] <br>
** [[Postpartum]] <br>
** Prior history of [[VTE]] <br>
** [[Thrombophilia]] <br>
** Advanced [[age]] <br>
** [[Laparoscopic surgery]] <br>
** Prepartum <br>
** [[Obesity]] <br>
** [[Varicose veins]]
* '''Triggers'''<ref name="pmid12814980">{{cite journal| author=Anderson FA, Spencer FA| title=Risk factors for venous thromboembolism. | journal=Circulation | year= 2003 | volume= 107 | issue= 23 Suppl 1 | pages= I9-16 | pmid=12814980 | doi=10.1161/01.CIR.0000078469.07362.E6 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12814980  }} </ref><ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref>
** [[Bone fracture]] ([[hip]] or [[leg]]) <br>
** [[Hip replacement surgery]]<br>
** Knee replacement surgery<br>
** [[General surgery|Major general surgery]]<br>
** [[Trauma|Significant trauma]]<br>
** [[Spinal cord injury]]<br>
** Athroscopic knee surgery<br>
** [[Central venous line]]s<br>
** [[Chemotherapy]]<br>
** Bed rest for more than 3 days <br>
** Prolonged car or air travel <br>
** [[Laparoscopic surgery]] <br>
** Prepartum <br>
* '''Previous episode of [[VTE]]'''
** Age
** Location
* '''Past medical history of diseases associated with hyperviscosity'''
** [[Atherosclerosis]]
** [[Collagen vascular disease]]
** [[Heart failure]]
** [[Myeloproliferative disease]]
** [[Nephrotic syndrome]]
** [[Autoimmune diseases]]
**[[Polycythemia vera]]
** [[Hyperhomocysteinemia]]
** [[Paroxysmal nocturnal hemoglobinuria]]
** [[Waldenstrom macroglobulinemia]]
** [[Multiple myeloma]]
* '''History of [[thrombophilia]]'''
** [[Factor V Leiden mutation]]
** [[Prothrombin gene mutation G20210A]]
** [[Protein C]] or [[Protein S]] deficiency
** [[Antithrombin]] (AT) deficiency
** [[Antiphospholipid syndrome]] (APS)
* '''Abortion'''
** [[Abortion]] at second or third trimester of [[pregnancy]] (suggestive of an inherited [[thrombophilia]] or APS)
* '''Drugs that may increase the risk of VTE'''
** [[Hydralazine]]
** [[Phenothiazine]]
** [[Procainamide]]
** [[Tamoxifen]]
** [[Bevacizumab]]
** [[Glucocorticoids]]
* '''Family history (suggestive of [[inherited thrombophilia]])'''
** Deep vein thrombosis
** Pulmonary embolism
** Recurrent [[miscarriage]]
* '''Social history'''
** Heavy [[cigarette smoking]] (>25 cigarettes per day)
** [[Intravenous drug use]] (if injected directly in [[femoral vein]])
** [[Alcohol]]


==References==
==References==

Latest revision as of 19:45, 6 March 2018
Resident
Survival
Guide

Editor(s)-In-Chief: The APEX Trial Investigators, C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2] ; Kashish Goel, M.D.; Justine Cadet; Rim Halaby, M.D. [3]

Deep Vein Thrombosis Microchapters

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Patient Information

Overview

Classification

Pathophysiology

Causes

Differentiating Deep vein thrombosis from other Diseases

Epidemiology and Demographics

Risk Factors

Triggers

Screening

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Approach

Assessment of Clinical Probability and Risk Scores

Assessment of Probability of Subsequent VTE and Risk Scores

History and Symptoms

Physical Examination

Laboratory Findings

Ultrasound

Venography

CT

MRI

Other Imaging Findings

Treatment

Treatment Approach

Medical Therapy

IVC Filter

Invasive Therapy

Surgery

Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Special Scenario

Upper extremity DVT

Recurrence

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Directions to Hospitals Treating Deep vein thrombosis

Risk calculators and risk factors for Deep vein thrombosis history and symptoms

Overview

A proper history and physical exam is very important for establishing an accurate diagnosis of deep vein thrombosis (DVT). DVT can be either asymptomatic or associated with tenderness and swelling of the calf or thigh. One of the first steps in the management of DVT is the determination of the Wells score for DVT, whose criteria can be ascertained solely on the basis of history and physical exam. A high index of suspicion is also necessary to diagnose DVT. DVT can be complicated by pulmonary embolism (PE); therefore, it is important to inquire about the symptoms of PE among patients suspected to have DVT.

History and Symptoms

As depicted in the image below, the majority of patients with venous thromboembolism (VTE), that is DVT, PE, or both, are asymptomatic.

The challenge in diagnosis of VTE

Common Symptoms of DVT

The classical symptoms of DVT include:

However, sometimes there may be no symptoms referable to the location of the DVT.

Shown below is a picture depicting unilateral swelling and redness in a leg affected with DVT.

Unilateral swelling and redness in a leg affected with DVT By James Heilman, MD - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=9444797


Less Common Symptoms of DVT

Symptoms of PE

Since VTE involves both DVT and PE, the patient can present with complaints of either of the diseases. Therefore it is important to inquire about the symptoms of both diseases. Symptoms of PE include:

Complete History

If VTE is suspected or diagnosed, a complete history should be elicited, including the following:

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 Cohen AT, Dobromirski M, Gurwith MM (2014). "Managing pulmonary embolism from presentation to extended treatment". Thromb Res. 133 (2): 139–48. doi:10.1016/j.thromres.2013.09.040. PMID 24182642.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P; et al. (2008). "Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)". Eur Heart J. 29 (18): 2276–315. doi:10.1093/eurheartj/ehn310. PMID 18757870.
  3. ↑ 3.0 3.1 Anderson FA, Spencer FA (2003). "Risk factors for venous thromboembolism". Circulation. 107 (23 Suppl 1): I9–16. doi:10.1161/01.CIR.0000078469.07362.E6. PMID 12814980.

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